Apparatus for mitral valve repair and methods thereof

ABSTRACT

A surgical snare assembly is disclosed. The surgical snare assembly has a suture fastener having an entrance and an exit. The surgical snare assembly also has first and second suture engaging loops. The surgical snare assembly further has first and second handles configured such that: a) movement of the first handle a first distance away from the suture fastener causes the first suture engaging loop to move through the suture fastener from the exit to the entrance; and b) movement of the second handle a second distance away from the suture fastener causes the second suture engaging loop to move through the suture fastener from the entrance to the exit.

RELATED APPLICATION

This patent application claims priority to U.S. Provisional PatentApplication No. 62/206,499 filed Aug. 18, 2015 and entitled “APPARATUSFOR MITRAL VALVE REPAIR AND METHODS THEREOF”. The 62/206,499 applicationis hereby incorporated by reference in its entirety.

FIELD

The claimed invention relates to surgical suturing, and morespecifically to minimally invasive surgical suturing devices for mitralvalve repair and methods thereof.

BACKGROUND

The human heart relies on a series of one-way valves to help control theflow of blood through the chambers of the heart. For example,deoxygenated blood returns to the heart via the superior vena cava andthe inferior vena cava, entering the right atrium. The heart muscletissue contracts in a rhythmic, coordinated heartbeat, first with anatrial contraction which aids blood in the right atrium to pass throughthe tricuspid valve and into the right ventricle. Following atrialcontraction, ventricular contraction occurs and the tricuspid valvecloses. Ventricular contraction is stronger than atrial contraction,assisting blood flow through the pulmonic valve, out of the heart viathe pulmonary artery, and to the lungs for oxygenation. Following theventricular contraction, the pulmonic valve closes, preventing thebackwards flow of blood from the pulmonary artery into the heart.

Oxygenated blood returns to the heart via the pulmonary veins, enteringthe left atrium. Left atrial contraction assists blood in the leftatrium to pass through the mitral valve and into the left ventricle.Following the atrial contraction, ensuing ventricular contraction causesmitral valve closure, and pushes oxygenated blood from the leftventricle through the aortic valve and into the aorta where it thencirculates throughout the body. Under nominal conditions, prolapse ofthe mitral valve is prevented during ventricular contraction by chordaeattached between the mitral valve leaflets and papillary muscles.Following left ventricular contraction, the aortic valve closes,preventing the backwards flow of blood from the aorta into the heart.

Unfortunately, one or more of a person's heart valves can have ordevelop problems which adversely affect their function and,consequently, negatively impact the person's health. Generally, problemswith heart valves can be organized into two categories: regurgitationand/or stenosis. Regurgitation occurs if a heart valve does not sealtightly, thereby allowing blood to flow back into a chamber rather thanadvancing through and out of the heart. This can cause the heart to workharder to remain an effective pump. Regurgitation is frequently observedwhen the mitral valve fails to close properly during a ventricularcontraction. Mitral regurgitation can be caused by chordae stretching,tearing, or rupturing, along with other structural changes within theheart.

Neochordal replacement for stretched or torn chordae is one option toreduce regurgitation. In such a procedure, chords to be replaced areidentified and dissected as required. A papillary suture is placed in apapillary muscle corresponding to the dissected chord. The papillarysuture may optionally be pledgeted on one or both sides of the papillarymuscle. A leaflet suture is also placed in the corresponding mitralvalve leaflet. The papillary suture and the leaflet suture may then betied or otherwise fastened together to create a replacement chord tohelp support the mitral valve leaflet and prevent regurgitation.

New minimally invasive surgical tools are becoming available whichgreatly facilitate placement of a single suture in both the papillarymuscle and a corresponding mitral valve leaflet. While this creates apotentially simplified replacement structure for a chordae tendinae,there is still a desire to reliably secure the ends of the single sutureas simply as possible in order to minimize the physiological footprintof the replacement structure. Hand-tied knots are difficult to form in aminimally invasive surgical setting. Mechanical knots are very reliable,but there is room for improvement in how such knots are applied.

Therefore, there is a need for efficient and reliable devices andmethods for minimally invasive mitral valve repair.

SUMMARY

A surgical snare assembly is disclosed. The surgical snare assembly hasa suture fastener having an entrance and an exit. The surgical snareassembly also has first and second suture engaging loops. The surgicalsnare assembly further has first and second handles configured suchthat: a) movement of the first handle a first distance away from thesuture fastener causes the first suture engaging loop to move throughthe suture fastener from the exit to the entrance; and b) movement ofthe second handle a second distance away from the suture fastener causesthe second suture engaging loop to move through the suture fastener fromthe entrance to the exit.

Another surgical snare assembly is disclosed. The surgical snareassembly has a suture fastener having an entrance and an exit. Thesurgical snare assembly also has a suture passed through the suturefastener with an entrance suture portion coming out of the entrance ofthe suture fastener and an exit suture portion coming out of the exit ofthe suture fastener, the suture having a ferrule coupled to the exitsuture portion. The surgical snare assembly further has a sutureengaging loop. The surgical snare assembly also has a handle coupled tothe suture engaging loop such that movement of the handle a firstdistance away from the suture fastener causes the suture engaging loopto move through the suture fastener from the entrance to the exit.

A suture fastener applicator is disclosed. The suture fastenerapplicator has a suture fastener receiver and a snare outlet. The suturefastener applicator also has a surgical snare assembly. The surgicalsnare assembly has a suture fastener having an entrance and an exit. Thesurgical snare assembly also has a suture passed through the suturefastener with an entrance suture portion coming out of the entrance ofthe suture fastener and an exit suture portion coming out of the exit ofthe suture fastener, the suture having a ferrule coupled to the exitsuture portion. The surgical snare assembly further has a sutureengaging loop. The surgical snare assembly also has a handle coupled tothe suture engaging loop such that movement of the handle a firstdistance away from the suture fastener causes the suture engaging loopto move through the suture fastener from the entrance to the exit. Theexit of the suture fastener is inserted into the suture fastenerreceiver, while the entrance faces outward. The entrance suture portionand the handle protrude out of the snare outlet. The exit suture portionprotrudes out of the suture fastener receiver.

A suture fastener is also disclosed. The suture fastener has a crimpablesleeve having an entrance and an exit. The suture fastener also has abase adjacent the entrance of the crimpable sleeve, wherein the base,when viewed from an entrance elevation, is longer in a first directionthan in a second direction substantially perpendicular to the firstdirection.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a partial cross-sectional view illustrating one embodiment ofa surgical snare assembly prior to being fully assembled.

FIG. 1B is a partial cross-sectional view of one embodiment of a fullyassembled surgical snare assembly.

In FIG. 1C, a distal end of a suture fastener applicator is introducedwith the surgical snare assembly of FIG. 1B.

FIGS. 1D-1F illustrate how the surgical snare assembly of FIG. 1B may beloaded into the suture fastener applicator of FIG. 1C to form a suturefastener applicator assembly.

FIG. 1F-1 is an enlarged view of FIG. 1F.

FIGS. 1G-1H illustrate one embodiment of a larger suturing assemblywhich may be formed by combining the suture fastener applicator assemblyof FIG. 1F with a minimally invasive suturing device.

FIG. 2 illustrates a surgical situation where a suture has been placedthrough a mitral valve leaflet and then through a papillary muscle.

FIGS. 3A-3F illustrate one embodiment of a method by which the sutureends of FIG. 2 may be fastened together to form a replacement chord byusing the suture fastener applicator assembly of FIG. 1F.

FIG. 4A illustrates one embodiment of a precursor surgical snareassembly which can advantageously be used to produce a surgical snareassembly, such as the surgical snare assembly embodiment illustrated inFIG. 4B.

FIG. 5A illustrates another embodiment of a precursor surgical snareassembly which can advantageously be used to produce a surgical snareassembly, such as the surgical snare assembly embodiment illustrated inFIG. 5B.

FIG. 6A illustrates a further embodiment of a precursor surgical snareassembly which can advantageously be used to produce a surgical snareassembly, such as the surgical snare assembly embodiment illustrated inFIG. 6C. FIG. 6B illustrates an intermediate step in the productionprocess between the precursor of FIG. 6A and the surgical snare assemblyof FIG. 6C.

FIG. 7A illustrates another embodiment of a precursor surgical snareassembly which can advantageously be used to produce a surgical snareassembly, such as the surgical snare assembly embodiment illustrated inFIG. 7C. FIG. 7B illustrates an intermediate step in the productionprocess between the precursor of FIG. 7A and the surgical snare assemblyof FIG. 7C.

FIG. 8 illustrates a further embodiment of a precursor surgical snareassembly.

FIG. 9 is a perspective view illustrating one embodiment of an improvedsuture fastener.

FIGS. 10A, 10B, 10C, and 10D illustrate front, right side, top, andbottom elevational views of the suture fastener embodiment of FIG. 9.

FIGS. 11A and 11B are side and front cross-sectional views,respectively, of the suture fastener embodiment of FIG. 9.

FIG. 12 illustrates one embodiment of a surgical snare assembly having asuture fastener like the suture fastener embodied in FIG. 9.

FIG. 13 is a perspective view illustrating another embodiment of animproved suture fastener, this embodiment being similar to theembodiment of FIG. 9, but also having one or more suture guides in thesides of the base of the suture fastener.

FIG. 14 illustrates another embodiment of a surgical snare assembly.

FIG. 15 presents a surgical situation in which a suture has been passedthrough a mitral valve leaflet, and then both ends of the suture havebeen passed down, through, and out of a papillary muscle.

FIGS. 16A-16D illustrate one embodiment of a method whereby the suturesnare assembly of FIG. 14 may be used in conjunction with a suturefastener applicator to apply the improved suture fastener embodiment ofFIG. 9 to the suture ends exiting the papillary muscle in order to forma replacement chord for the mitral valve.

It will be appreciated that for purposes of clarity and where deemedappropriate, reference numerals have been repeated in the figures toindicate corresponding features, and that the various elements in thedrawings have not necessarily been drawn to scale in order to bettershow the features.

DETAILED DESCRIPTION

FIG. 1A illustrates a surgical snare assembly 30 prior to being fullyassembled. The surgical snare assembly 30 has a suture fastener 32 withan entrance 34 and an exit 36. The suture fastener 32 is illustrated ina cross-sectional view to better illustrate the channel passingtherethrough from the entrance 34 to the exit 36. The assembly 30 alsohas a suture engaging loop 38 coupled to a handle 40. In thisembodiment, the handle 40 is positioned on the exit 36 side of thefastener 32, while the suture engaging loop 38 is positioned on theentrance 34 side of the fastener 32. Movement of the handle 40 a firstdistance away from the suture fastener 32 will cause the suture engagingloop to be pulled through the suture fastener 32 from the entrance 34 tothe exit 36. A suture 42 having a first end 44 and a second end 46 isalso present. A ferrule 48 is coupled to the second end 46 of the suture42. The ferrule 48 is configured to be able to engage a suturing needle(none shown) such that the needle can pull the ferrule 48 (and itscorresponding suture) through tissue which the needle has pierced.

In FIG. 1A, the first end 44 of the suture 42 has not been passedthrough the suture fastener 32 yet, although an intended path 50 for thesuture end 44 is illustrated. FIG. 1B illustrates the fully assembledsurgical snare assembly 30 with the first suture end 44 passed throughthe suture fastener 32. An entrance suture portion 52 protrudes out ofthe entrance 34 of the suture fastener 32, while an exit suture portion54 protrudes out of the exit 36 of the suture fastener 32. The ferrule48 is coupled to the exit suture portion 54.

In FIG. 1C, a distal end of a suture fastener applicator 56 isintroduced. The applicator 56 has a suture fastener receiver 58 and asnare outlet 60. Such suture fastener applicators 56 are known to thoseskilled in the art. As just one example, the COR-KNOT® device from LSISolutions, Inc. of Victor, N.Y. (www.lsisolutions.com) is one suchdevice. The entrance suture portion 52 of the surgical snare assembly 30will be threaded on path 62 through the suture fastener receiver 58 andout of the snare outlet 60 as shown in FIG. 1D.

In FIG. 1E, the handle 40 is brought towards the suture fastenerapplicator 56. The handle 40 of the surgical snare assembly 30 will bepassed on path 64 through the suture fastener receiver 58 and out of thesnare outlet 60 as shown in FIG. 1F.

FIG. 1F-1 is an enlarged view of FIG. 1F. The exit 36 of the suturefastener 32 has been inserted into the suture fastener receiver 58,while the entrance 34 faces outward. For ease of explanation, the suturefastener 32 is only shown partially inserted into the suture fastenerreceiver 58 so that the suture paths may be seen more clearly. Inpractice, however, the suture fastener 32 could be inserted more fully.Other illustrations also follow this convention. The entrance sutureportion 52 and the handle 40 protrude out of the snare outlet 60. Theexit suture portion 54 protrudes out of the suture fastener receiver 58.The assembly illustrated in FIG. 1F-1 may be referred to as a suturefastener applicator assembly 66.

The suture fastener applicator assembly 66 may be part of a largersuturing assembly 68 illustrated in FIGS. 1G and 1H. The ferrule 48 maybe passed on a path 70 such that it is installed in a ferrule receiver72 of a minimally invasive suturing device 74. Minimally invasivesuturing devices are known to those skilled in the art. One exemplarydevice is the RD180® from LSI Solutions, Inc. of Victor, N.Y.(www.lsisolutions.com)

The suture 42 is long enough that the suturing device 74 may be used toplace suture stitches in a patient at one or more desired locations. Forexample, a surgical situation is illustrated in FIG. 2. The suture 42has been placed through a mitral valve leaflet 76 and then through apapillary muscle 78. The ferrule 48 has been released from the suturingdevice 74 (not shown) and the suture portion A (part of the exit sutureportion 54) passes back to the suture fastener applicator assembly 66 ofFIG. 1F-1 (not shown in this view). FIG. 3A schematically illustratesthis surgical situation, including the suture fastener applicatorassembly 66. The ferrule 48 can be passed along the path 80 through thesuture engaging loop 38 as shown in FIG. 3B. Suture portions A and B arepart of the exit suture portion 54, but suture portion A is between thetissue 76, 78 and the suture fastener applicator assembly 66, whilesuture portion B is between the second end 46 of suture 42 and thetissue 78, 76. The entrance suture portion 52 which exits the snareoutlet 60 is labelled suture portion C.

The ferrule 48 shown in FIG. 3B may be cut off the second suture end 46,resulting in the situation shown in FIG. 3C, where the suture portion Bis still passed through the suture engaging loop 38. The handle 40 maybe pulled in direction 82, causing the suture engaging loop 38 to pullthe suture portion B through the entrance 34 of the suture fastener 32,out the exit 36 of the suture fastener 32, and out the snare outlet 60as illustrated in FIG. 3D. The suture portions C and B (corresponding tothe first and second suture ends 44, 46) are now together, protrudingfrom the snare outlet 60.

As shown in the enlarged view of FIG. 3E, the suture fastener applicator56 is moved 84 so that the entrance 34 of the suture fastener 32 isplaced against the papillary muscle 78, while the suture ends B and Care tensioned 86 individually and/or separately to achieve a desiredsuture length between the mitral leaflet 76 and the papillary muscle 78.Given the routing of the suture, it may be easiest to adjust suture endB. When the desired suture length is achieved, the suture fastenerapplicator 56 is activated, causing the suture fastener 32 to fastenonto the suture passing therethrough. In this example, the suturefastener applicator 56 crimps the suture fastener 32, the suture ends Band C can be trimmed, and the suture fastener applicator 56 can beremoved, resulting in the secured suture 42 illustrated in FIG. 3F. Thissecured single suture acts as a replacement chordae tendinae as part ofa mitral valve repair procedure.

FIGS. 4A, 5A, 6A, 7A, and 8 all illustrate different embodiments of aprecursor surgical snare assembly 88, 90, 92, 94, 96, respectively,which can be advantageously used to produce a surgical snare assemblysuch as assembly 30 of FIG. 1B, or its equivalent. Each precursorsurgical snare assembly includes a suture fastener 32 having an entrance34 and an exit 36. The assembly 88 of FIG. 4A has first and secondsuture engaging loops 98, 100. A first handle 102 is coupled to thefirst suture engaging loop 98, while a second handle 104 is coupled tothe second suture engaging loop 100. The handles 102, 104 are configuredsuch that movement of the first handle 102 a first distance away fromthe suture fastener 32 causes the first suture engaging loop 98 to movethrough the suture fastener 32 from the exit 36 to the entrance 34.Furthermore, movement of the second handle 104 a second distance awayfrom the suture fastener 32 causes the second suture engaging loop 100to move through the suture fastener 32 from the entrance 34 to the exit36. A suture end 44 may be inserted into the first suture engaging loop98, and subsequently pulled through the suture fastener 32 from the exit36 to the entrance 34 by pulling the first handle 102 as illustrated inFIG. 4B. The first suture loop 98 and its coupled first handle 102 maybe set aside, and the remaining surgical snare assembly 30 is ready foruse as discussed above.

The assembly 90 of FIG. 5A has first and second suture engaging loops106, 108. The second suture engaging loop 108 also acts as a firsthandle 110, and it is coupled to the first suture engaging loop 106. Theassembly 90 also has a second handle 112 which is indirectly coupled tothe second loop 108. The handles 110, 112 are configured such thatmovement of the first handle 110 a first distance away from the suturefastener 32 causes the first suture engaging loop 106 to move throughthe suture fastener 32 from the exit 36 to the entrance 34. Furthermore,movement of the second handle 112 a second distance away from the suturefastener 32 causes the second suture engaging loop 108 to move throughthe suture fastener 32 from the entrance 34 to the exit 36. A suture end44 may be inserted into the first suture engaging loop 106, andsubsequently pulled through the suture fastener 32 from the exit 36 tothe entrance 34 by pulling the first handle 110 as illustrated in FIG.5B. The remaining surgical snare assembly 114 is ready for use asdiscussed above, with either loop 106, 108 available for use as thesuture engaging loop 38 from FIG. 1A.

The assembly 92 of FIG. 6A has a suture engaging loop 116 which is botha first suture engaging loop and a second suture engaging loop. A firsthandle 118 is coupled to the suture engaging loop 116 (which operates asa first suture engaging loop when it is on the exit side of thefastener), while a second handle 120 is coupled to the suture engagingloop 116 (which also operates as a second suture engaging loop when itis on the entrance side of the suture fastener). The handles 118, 120are configured such that movement of the first handle 118 a firstdistance away from the suture fastener 32 causes the first sutureengaging loop 116 to move through the suture fastener 32 from the exit36 to the entrance 34. Furthermore, movement of the second handle 120 asecond distance away from the suture fastener 32 causes the secondsuture engaging loop 116 to move through the suture fastener 32 from theentrance 34 to the exit 36. A suture end 44 may be inserted into thefirst suture engaging loop 116, and subsequently pulled through thesuture fastener 32 from the exit 36 to the entrance 34 by pulling thefirst handle 118 as illustrated in FIG. 6B. The first suture handle 118may be removed and set aside as shown in FIG. 6C, and the remainingsurgical snare assembly 30 is ready for use as discussed above.

The assembly 94 of FIG. 7A has a suture engaging loop 122 which is botha first suture engaging loop 124 (on the exit side of the suturefastener) and a second suture engaging loop 126 (on the entrance side ofthe suture fastener). The second suture engaging loop 126 is also thefirst handle 128. The first handle 128 is coupled to the first sutureengaging loop 124, while a second handle 130 is coupled to the secondsuture engaging loop 126. The handles 128, 130 are configured such thatmovement of the first handle 128 a first distance away from the suturefastener 32 causes the first suture engaging loop 124 to move throughthe suture fastener 32 from the exit 36 to the entrance 34. Furthermore,movement of the second handle 130 a second distance away from the suturefastener 32 causes the second suture engaging loop 126 to move throughthe suture fastener 32 from the entrance 34 to the exit 36. A suture end44 may be pinched between the first suture engaging loop 124, andsubsequently pulled through the suture fastener 32 from the exit 36 tothe entrance 34 by pulling the first handle 128 as illustrated in FIG.7B. The remaining surgical snare assembly 30 illustrated in FIG. 7C isready for use as discussed above. It should be noted that the loop 122is shown shortened for convenience in FIG. 7C, and is not drawn incorresponding scale with FIGS. 7A and 7B.

The precursor surgical snare assembly 96 of FIG. 8 shows an alternateembodiment of the FIG. 4A assembly where the first and second handles132, 134 are made from loose ends of the first and second loops 136,138. Operation of this precursor assembly 96 is otherwise like that ofprecursor assembly 88. Other embodiments are possible with a mix ofhandle types, and those skilled in the art will readily understand thatmany handle types may be used in light of the teaching of thisspecification.

FIG. 9 illustrates one embodiment of an improved suture fastener 140 ina perspective view. FIGS. 10A, 10B, 10C, and 10D illustrate front, rightside, top, and bottom elevational views of the suture fastener 140. Thesuture fastener 140 has a crimpable sleeve 142 having an entrance 144and an exit 146. The improved suture fastener 140 also has a base 148adjacent the entrance 144 of the crimpable sleeve 142. When viewed froman entrance elevation, such as from FIG. 10D, the base is longer in afirst direction 150 than in a second direction 152 substantiallyperpendicular to the first direction 150. In some embodiments, thepreferred ratio of the length of the base 148 in the first direction 150to the length of the base 148 in the second direction 152 isapproximately 2:1, although other embodiments may have smaller orgreater ratios, provided the ratio is substantially greater than 1:1.FIG. 11A is a cross-sectional view of the suture fastener 140 of FIG.10A, taken along cross-section line 11A-11A. FIG. 11B is across-sectional view of the suture fastener of FIG. 10B, taken alongcross-section line 11B-11B.

As illustrated in FIG. 12, a suture fastener 140, such as the suturefastener of FIG. 9, may be used as part of a surgical snare assemblysuch as those discussed previously. It should be noted, however, thatthe surgical snare assemblies are not necessarily limited to having asuture fastener of a particular shape. If a suture fastener 140 such asthe one shown in FIG. 12 is used, however, the suture fastener receiver156 may be given a corresponding shape so that the orientation of therounded rectangular base may be known relative to the applicator 158.

The exit suture portion 54 and the entrance suture portion 52 are routedpast opposite sides of the base of suture fastener 140 in the example ofFIG. 12. As illustrated in FIG. 13, it may be advantageous in someembodiments to provide one or more suture guides 160 in the sides of thebase 148 of the suture fastener 162. The suture guides 160 can be usedto help ensure the exit suture portion 54 and the entrance sutureportion 52 are routed as desired relative to the base. This can help toensure the exit and entrance suture portions 54, 52 do not interferewith the crimping action of the fastener applicator which holds thesuture fastener.

As illustrated in FIG. 14, a suture fastener 140 (the features of whichhave been discussed above) may be used as part of a surgical snareassembly 164 which has a suture engaging loop 166 passing through theentrance 144 of the fastener 140 and coupled to a handle 168 on the exit146 side of the fastener. Such an assembly is useful for a variety ofprocedures, including a mitral valve repair procedure.

For example, consider the surgical situation presented in FIG. 15. Asuture 170 has been passed through a mitral valve leaflet 76, and thenboth ends 172, 174 of the suture 170 have been passed down through andout of a papillary muscle 78. As illustrated in FIG. 16A, the snareassembly 164 of FIG. 14 may be installed in a suture fastener applicatoras shown. The suture ends 172, 174 may be passed along paths 176, 178,through the suture engaging loop 166, and then the handle 168 may bepulled 180, resulting in the suture ends 172, 174 being drawn throughthe entrance 144 of the suture fastener 140, out the exit 146 of thesuture fastener, and out of the snare outlet 182 of the applicator 158as shown in FIG. 16B.

As shown in the enlarged view of FIG. 16C, the suture fastenerapplicator 158 is moved so that the entrance of the suture fastener 140is placed against the papillary muscle 78, while the suture ends 172,174 are tensioned 184 individually and/or separately to achieve adesired suture length between the mitral leaflet 76 and the papillarymuscle 78. When the desired suture length is achieved, the suturefastener applicator 158 is activated, causing the suture fastener 140 tofasten onto the suture passing therethrough. In this example, the suturefastener applicator 158 crimps the suture fastener 140, the suture ends172, 174 can be trimmed, and the suture fastener applicator 158 can beremoved, resulting in the secured suture 170 illustrated in FIG. 16D.This secured single suture 170 acts as a replacement chordae tendinae aspart of a mitral valve repair procedure. When secured as shown in FIG.16D, the suture fastener 140 will tend to lie down by pivoting on anaxis 186 substantially parallel to the longer dimension of the base.This pivoting action does not tend to occur as easily for suturefasteners with bases that are round. By positioning the suture fastenersuch that an axis 186 of the longer dimension is substantiallyperpendicular to a line drawn from the bottom 188 of the papillarymuscle 78, the suture fastener 140 will tend to point down toward thebottom 188 of the muscle 78, thereby keeping it more out of the way ofthe heart's chamber and the structures therein. This may improve bloodflow through the chamber while still allowing the chordae tendinae to berepaired.

Various advantages of an apparatus for mitral valve repair and methodsthereof have been discussed above. Embodiments discussed herein havebeen described by way of example in this specification. It will beapparent to those skilled in the art that the foregoing detaileddisclosure is intended to be presented by way of example only, and isnot limiting. Various alterations, improvements, and modifications willoccur and are intended to those skilled in the art, though not expresslystated herein. These alterations, improvements, and modifications areintended to be suggested hereby, and are within the spirit and the scopeof the claimed invention. Additionally, the recited order of processingelements or sequences, or the use of numbers, letters, or otherdesignations therefore, is not intended to limit the claims to anyorder, except as may be specified in the claims. Accordingly, theinvention is limited only by the following claims and equivalentsthereto.

What is claimed is:
 1. A surgical snare assembly, comprising: a suturefastener having an entrance and an exit; first and second sutureengaging loops; first and second handles configured such that: movementof the first handle a first distance away from the suture fastenercauses the first suture engaging loop to move through the suturefastener from the exit to the entrance; and movement of the secondhandle a second distance away from the suture fastener causes the secondsuture engaging loop to move through the suture fastener from theentrance to the exit.
 2. The surgical snare assembly of claim 1, whereinthe second suture engaging loop comprises the first handle.
 3. Thesurgical snare assembly of claim 1, wherein the first suture engagingloop comprises the second suture engaging loop.
 4. The surgical snareassembly of claim 3, wherein the second suture engaging loop comprisesthe first handle.
 5. The surgical snare assembly of claim 3, wherein thefirst handle is removable.
 6. The surgical snare assembly of claim 1,wherein at least one of the first and second handles comprises one ormore ends of the first or second suture engaging loops.
 7. A surgicalsnare assembly, comprising: a suture fastener having an entrance and anexit; a suture passed through the suture fastener with an entrancesuture portion coming out of the entrance of the suture fastener and anexit suture portion coming out of the exit of the suture fastener, thesuture having a ferrule coupled to the exit suture portion; a sutureengaging loop; a handle coupled to the suture engaging loop such thatmovement of the handle a first distance away from the suture fastenercauses the suture engaging loop to move through the suture fastener fromthe entrance to the exit.
 8. The surgical snare assembly of claim 7,wherein the entrance suture portion is coupled to the handle andconfigured to enable part of the entrance suture portion to be loadedinto a suture fastener applicator when the handle is loaded into thesuture fastener applicator.
 9. A suture fastener applicator, comprising:a suture fastener receiver; a snare outlet; the surgical snare assemblyof claim 7, wherein: the exit of the suture fastener is inserted intothe suture fastener receiver, while the entrance faces outward; theentrance suture portion and the handle protrude out of the snare outlet;and the exit suture portion protrudes out of the suture fastenerreceiver.
 10. A suture fastener, comprising: a crimpable sleeve havingan entrance and an exit; and a base adjacent the entrance of thecrimpable sleeve, wherein the base, when viewed from an entranceelevation, is longer in a first direction than in a second directionsubstantially perpendicular to the first direction.
 11. The suturefastener of claim 10, wherein the ratio of a length of the base in thefirst direction to a length of the base in the second direction isapproximately 2:1.
 12. The suture fastener of claim 10, wherein the basecomprises a rounded rectangular shape.
 13. The suture fastener of claim10, wherein the base further comprises one or more suture guides on anedge of the base.
 14. The surgical snare assembly of claim 1, whereinthe suture fastener of claim 1 comprises the suture fastener of claim10.
 15. The suture fastener applicator of claim 9, wherein the suturefastener receiver is configured to receive the surgical snare assemblyof claim
 14. 16. The suture fastener applicator of claim 15, furthercomprising a known orientation of between a user-identifiable portion ofthe suture fastener applicator and a direction of the base of the suturefastener.